How many more physicians will we lose to suicide?

Almost two years ago I went to the funeral of a medical school classmate. A little more than three weeks before he had jumped from a parking garage after finishing his clinic. He had a loving wife and three young children. He had the respect of his colleagues and the love of his patients. There was nothing out of the ordinary in his financial or personal life. It didn’t make sense, but it rarely does. Something broke inside the mind of someone I have always known to be a happy, easygoing person.

I don’t know why he committed suicide. It seemed to be related to a recent period of intense, severe depression. I don’t know if the pressures of being a physician were a factor, but I do know that physicians have one of the highest, if not the highest suicide rate of any profession; nearly twice the rate of suicide compared to the general population. It may actually be higher. There is tremendous social and institutional pressure to label a death an accident instead of a suicide when ambiguous. If any cohort of people could make suicide look like an accident or death from natural causes, it would be someone in the medical profession.

Of my medical school class of about one hundred, two have been lost to suicide before my 41st birthday. The first was before we even finished medical school. Why do we lose so many physicians to suicide and how many more will be lost?

There are pressures to being a physician that are unseen by most people not working in the medical field. Rates of burnout and major depression are higher in medical students and physicians, and we tend to not seek treatment. Why would we? There is a stigma to mental health problems. Many people view them as a weakness rather than a serious and very real disease. We would never view one of our patients this way, but sometimes we do treat our peers and ourselves this way. Physicians are often afraid to seek help because of fear of losing their medical license, hospital privileges or malpractice insurance. The inconsistency of treatments prescribed by medical boards and physician ‘help’ programs discourages those who need help the most to seek it. If you know a colleague who has gone through this process you know exactly what I mean. Some of these programs cause more economic stress, guilt, shame and depression than they cure. They are a blunt instrument.

Many medical schools and residency programs teach us to “suck it up” and “tough it out,” not to seek help. Maybe not always explicitly, but this is the culture. Residency is a time of being constantly sleep deprived, stressed out and living a very unbalanced life. Work-life balance, whatever that means, is an abstract concept. It is not hard to imagine why a resident would have a higher rate of suicide, but my friend was a decade into his practice.

In some ways, life and practice are easier after residency but in other ways, they are much more difficult. The time commitments are generally less with fewer sleepless nights on-call, but the pace increases and the stress never really goes away. The administrative and bureaucratic realities of practicing medicine weave their way into daily life. These facts surprised me my first few years of practice, and medicine has seemed only to increase in complexity over the last decade.

I became good at managing the stress, though, and by this, I mean suppressing the negative feelings. Physicians are good at delayed gratification. We are good at telling ourselves we are living “normal” lives when anyone living outside of medicine would never consider our existence normal. We tell ourselves it is normal because compared to residency, it kind of is in a perverse way. It works for a while, and many are able to do it their whole careers, but some can’t. I was good at it right up until the point that I wasn’t.

Being a doctor can feel very confining at times. There is an upfront investment of time and money that is greater than most professions. The “real job” often doesn’t start until your early 30s (if you have gone straight through college, medical school, and residency) and at the end of training, you have walked so far down the path it’s all you know. What if it’s not what you expected? What if you hate it? What if it’s no longer fulfilling? The chronic stress of being a physician can manifest itself as depression, anxiety, failed relationships, substance abuse or even suicide. I’ve seen all of these scenarios up close either in myself or others.

Every step of the way for me was different than I expected.

Being a physician is a huge piece of your identity. Walking away is like your ego jumping on a hand grenade. Some can do it, but it takes a certain amount of inner strength and self-knowledge. It can be a very lonely place with a mountain of student loan debt and a stressful job that you hate. I can’t know for sure, but I’m guessing a large percentage of physician suicides are due to these factors. When trapped like this suicide seems like the only way out of the cage for some.

I don’t know how much of a factor my friend’s job was in his suicide. I think he loved this profession or, at least, significant parts of it. All evidence would point to this — but there is something dark in being a physician that breaks some of us. Something we don’t like to talk about. Something we cover up. I don’t think he was looking for an escape from medicine, but it’s impossible to know for sure.

Another doctor will take his place, and his patients will find the care they need. His family and friends will mourn and eventually find a way to cope with the loss, but at what cost? There has been and will continue to be great suffering and unimaginable pain along the way.

I recently spoke to my friend’s wife about the suicide, the depression and all the events surrounding this tragedy. It took me a year and a half to even do that. Time has healed some of the wounds, but I could feel the deep underlying sadness behind the conversation, scars that would always be there. It was palpable, and I hated it, but needed to feel it at the same time. It exposed my own grief; something that almost two years later I am still trying to figure out how to deal with. A wife lost her husband, children lost their father, and I lost my friend. It seems so unfair.

Behind my grief though is fear and guilt. Fear that I’m not so different than my friend. Fear that this could happen to someone else I love. Fear that this could have been me under different circumstances. Guilt that I blindly stumble along in a system I know to be broken. A system I know will destroy the lives and families of other physicians. Guilt of knowing I’m doing nothing to help fix it.

I don’t know if I should cry or scream in anger, but I do know that nearly two years later I still think about this. This changed me. For better or worse I am different now.

Statistics are an abstraction, not real. My medical school classmates were the most real thing in my life for four years. Our shared experience and consciousness was unique, and we formed a tribe unseen by the rest of society. Losing anyone to suicide is a tragedy, but losing one of my own is real. It hurts. It’s terrible.

I felt nothing the day I heard the news. Nothing. I suppressed it because deep down I lost a part of myself that day. I pushed it away like all the other negative things in my life. I buried the emotions and only now am I facing them. I wish I could go back and change something, but I can’t.

I f*cking hate that fact.

I miss my friend, and I’m sorry I failed him.

I hope he found peace.

Note: It took me nearly two years to write this essay. Even after thinking and reading about this topic for all this time I still have more questions than answers. Thank you for reading.

Silence will not save us. I commend you for writing and speaking out about this topic that has been covered up by our medical institutions for far too long. One favor to help destigmatize the conversation around suicide. Please do not use the term “committed suicide” as committed would indicate a crime. Suicide is the end result of suffering, pain, and hopelessness.
It is not a crime.

And to answer your question: How many more physicians will we lose to suicide? A whole lot more. Unless we do something. I’ve dedicated the last 3.5+ years of my life to preventing medical student and physician suicide. Then one day my therapist said, “You know you can’t solve a problem nobody knows exists.” Yep. First step to addressing this crisis is to increase public awareness and decrease professional denial. Yes, there are still doctors who don’t think this such is a big deal. Many feel we should screen “these people” out of med school. Problem is these people were normal when they started med school. Our medical education and training may in fact be the culprit.

anonymous

Thank you for bringing up this topic. The stigma is real, and sometimes I think healthcare professionals are the worst about it. How many times have I heard classmates jokingly make comments about “crazy” patients? Or nurses/physicians judging a patient before they go into a room because a mental illness is on the chart – perhaps leading them not to take their complaints as seriously and dismissing them as secondary to that diagnosis? As a medical student, there’s no way I would let colleagues know that I have bipolar disorder and was hospitalized in the past for psychosis. Others’ opinions of my competence would assuredly be altered, and particularly in the case of residency directors, they would likely see me as a potential liability even if my illness is well-managed.

I don’t have a solution. Perhaps more education about mental illness and what they actually are would help. It is surprising how many laypeople at least think bipolar disorder is just having unstable moods that change within seconds throughout the day. But until both healthcare workers as well as the general public start accepting mental illness as the same as any other physical illness (just of the brain instead) and how common it is, we will likely stay in the closet. Things like homosexuality have become less stigmatized during my generation – maybe mental illness will be next.

Mike Henderson

You are exactly correct – letting anyone know about your diagnosis would be like bleeding yourself while swimming with sharks. Perhaps not all the sharks would tear you apart, but all it takes is one.

I was once naive and thought that if I told my adviser the areas I thought I needed improvement, she would provide some guidance or feedback. Nope. I learned that you have to “fake it until you make it.” Act like you know what you are doing no matter how little you know. But by god, don’t have self insight to know what needs improving. I have seen a thoracic surgeon deny an NG tube she put it wasn’t in the stomach, despite the x-ray clearly showing it curled up in the apex of the right lung, never crossing the diaphragm.

Mike Henderson

We never really know what something is like until it has been experienced first hand. If I could have known going into medicine what I know now, I would certainly have done things differently. But exactly what is speculative.

Some argue that what is going on is the norm and is up to the individual to figure out how to deal with the system successfully, however, there is profound, widespread and increasing disappointment in the medical field. When in residency, I frequently engaged older physicians about how medicine has changed over the decades and figured out, my dissatisfaction is par for the course. I have no special grievances compared to others. Recently an article was published studying the mental health of medical students and compared them to practicing physicians. We start out as having excellent mental health, but at the end of training, we have worse mental health than the general population and all other professions, as I recall.

There are techniques and skills one can employ to mitigate the adverse environment we practice in, but like any compensatory measure, they will never return things to a healthy state. In fact, compensatory measures can enable the diseased state to persist and become part of the pathologic process.

Bottom line is the system is sick and harms both patients and physicians. Do your best to not contribute and enable it. Take care of yourself first and foremost, every day.

goonerdoc

I’m sorry to hear about your friend. It’s an absolute tragedy. Here’s the thing though….the general public could give a rat’s about it. Remember, we’re doctors, and thus we’re swimming in cash like Scrooge McDuck. Because of this perception, we get no sympathy for anything else, no matter how horrible it may be.

querywoman

It’s hard to know what to say, other that I am glad you finally got up the courage to write it up, even anonymously.
The anonymity of the internet can be a real blessing.
Suicides probably occur in other training programs, don’t know how they compare to lengthy medical training.
He’s a life lost, a valuable human life, not just someone to be replaced.
Yeah, the medical training powers-that-be could loosen up the “suck it up” attitude. The profession that supplies the mental drugs should also open up about its own using them.

guest

I am not sure what we expect. Take a population of highly educated, intelligent professionals who are interested in connecting with people and helping them. Make them spend years (and in many cases, hundreds of thousands of dollars) on their training, so that they are trapped into the career. Make the selection process and the training so grueling that they develop a tendency to compete with peers rather than affiliate. Make the work so demanding that the only way it can be coped with is to adopt a semi-grandiose machismo about self-sacrifice and self-neglect.

Then make the work itself increasingly like being a factory worker, with micromanagement by less-educated administrators who have no familiarity with the work flow. Press for greater and greater “productivity” so that the doctor doesn’t actually have time to spend accurately determining what’s wrong with the patient, or how to treat it. At the same time, hold the doctor accountable for “quality metrics” that have nothing at all to do with what the patient wants from the encounter. But also measure the “patient satisfaction” of those same patients, who are not having their needs met by a system that is set up to deny them care through “population health management,” and hold the physician accountable for “patient satisfaction” as well.

Of course workers who are highly trained and dedicated, but personally isolated, will respond to being trapped in a professional catch-22 by becoming hopeless and despairing. And a certain number of them will commit suicide. They are the collateral damage in our winner-take-all society.

PamelaWibleMD

Yep. You nailed it.

DZ-015, M.D.

I worry about some of these medical students writing on this site. They seem to think they have all the answers we’ve somehow missed in the last thirty years and that they will work in a creative autonomous environment where their special genius and unique compassion and wordsmithery will be appreciated by admins and patients. Hubris, debt, lack of autonomy, realizing you are not being appreciated for sacrificing the best years of your life. This is a setup for disaster. This problem is going to get a lot worse.

guest

Actually, since a majority of them appear to be gunning for administrative rather than clinical positions, it’s not necessarily a disaster for them, although it might be a disaster for those of us who really want to keep on seeing patients….

W. X. Wall

I have a close friend who battled depression and attempted suicide. It was a long time ago when we were very young and thankfully, he made it through and is doing fine now. I remember someone saying that suicide isn’t the act of killing oneself, it’s the act of murdering every person that loves you. That’s what it feels like when someone close to you feels that life is no longer worth living.

I know I personally went through my own self-doubt, thinking, “if his life is so bad, is my life (being so similar to his) bad too?” or “how could he think his life is so bad when I and all these other people are in it? Is our friendship and love not enough to get him through?”

I think one of the reasons people are afraid to help a close relation contemplating suicide is because we’re afraid of what it says about our life, and that we could very easily get drawn into the same malaise afflicting him. When a suicidal patient assesses his life and deems it not worth living, it throws our own life up for re-assessment. That’s on top of whatever social stigma might be associated with mental disease that keeps people hushed up.

So I would say this to the original author: while you’re right to question whether our field leads people to a higher risk of suicide, and we should absolutely reduce those factors when we find them, don’t for a second let someone else’s suicidal ideations draw you into their own world of doubt and despair. Not only will it harm you, it will prevent you from providing the help and support that person needs.

QQQ

It’s fascinating: For those who wish to practice as a hospital based physician these days (which doesn’t include most primary care physicians) – a 4 year degree from a college is worthless without acceptance to a medical school – another 4 years – and a degree from which is worthless without acceptance to a residency – usually another 4 years on average – the completion of which is worthless without board certification (a lot of #$%$ studying) – the completion of which is worthless without the credentialing and these days employment by a hospital – the completion of which is worthless without ongoing, career long re-credentialing and re-certification the completion of which is worthless without the support of your family which these days can be tenuous given the high divorce rate among physicians, the successful completion of which is worthless without avoiding suicide, accomplished by 400 physicians every year…..the equivalence to a medical school class

QQQ

But, but, but,…..I thought these doctors were the baaaad greedy heartless healthcare providers that only care about their HUGE bank accounts, their 5 vacation homes, their 3 yachts, their 10 sports cars, while living in their mansions talking about their stock portfolios at their lavishing dinner parties!

You mean they have feelings like us and have problems like ordinary common people do as well???